GW1-2021-00669_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
(1 ra d Poo 14.WATER ZO
Well Contractor Nude FROM TO DESCRIPTION
ft. 30 f` 1 3 1
I
NC Well Contractor Certification Number 15.OUTER CASING Ifor moltl-eased wells)OR LINER lieabie
H r a�Y P0a ItL dell FROM ft. TO DIAMETER In TEnCKNESS MATERIAL
Company Name 0ID tt. v G
16:14NER CASING OR TUBING eothertnal.closedaoo
2.Well Construction Permit#: FROM TO DL1ArEfER TRICI'NESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): fL- ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipaUPublic ft. ". id
Geothermal(Heating/Cooling Supply) , Residential Water Supply(single) ft. it, tri.
lndustriaUCommercial DResidential Water Supply(shared)
I&GROUT
7IIrrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. D ft Porf 4
Monitoring Recovery ft. ft.
Injection Well: ft. it.
Aquifer Recharge Groundwater Remediation
14.5ANDlGRAVEL PACK(if a Itcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT M[TAOD
Aquifer Test [3Stormwater Drainage it• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets 9 necessary)
Geothermal(Heatin Coolin Return) Other E9r lain under#21 Remarks) FROM TO DES n'TION color,hardness,saivrock n etc
4.Date Well(s)Completed: �r y -a i Well ID# �.7 ft' 21 ft' t( r0
Su.Well Location: ft• ft.
ke : lie ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft.
_ l y l 604 V� iP rEWQQ. / � ft. ft.
Physical Address,City,and Zip ft. ft. 1
V V k k t, 21.REMARKS
County Parcel Identification No.(PIN) `-FQC:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loug is sutFcicnt) 22.Cer lion:
N W
6.Is(are)the wen(s)i4Per manent or Temporary Simotwe Co Date
By signing this form,l h by certo that the ive/l(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with MA NCAC 02C.0 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate'TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �1 W� �(ft) 24a. For All Wells: Submit this fortrt within 3Q days of completion of well
For multiple wells list all daptiu{j'dlerettt(example-3300'ands2�(i jIUU) construction to the following: y
10.Static water level below top of casing: 4�'� (ft.). Division of Water Resources,Information Processing Unit,
Ifwruer level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in•) 24b.For Iniectlon Wells: In addition to sending the form to the address in 24a
( r- A r above, also submit one copy of this form within 30 days of completion of well
]2.Well construction method: r Y �
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ®� 24c.For Water Supply&Iniection Wells: In addition to sending the form to
��� ) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:- -I=-- Amount: ' Ib completion of well construction to the county health department of the county
where constructed.
__--_Form GW 1— ---- - North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016